Sr. Utilization Management Nurse RN - Field Position
About The Position
Optum is seeking a Senior Utilization Management Nurse RN for a field-based position serving the Boston, Massachusetts regional area. The role supports onsite audits and projects across the Commonwealth of Massachusetts, with daily driving to different facility locations. Travel within the geographic territory is required at least 90% of the time, and some weeks may require 100% travel based on business needs. The role has no weekend, holiday, or on-call work; collaborative team scheduling is used, and occasional remote work may be available based on business needs. The nurse ensures the accuracy of Minimum Data Set (MDS) coding, supports proper payment to nursing facilities, and promotes quality patient care. This includes auditing assessments and medical records, reviewing clinical documentation and treatment, assessing medication use and other clinical indicators, and applying clinical judgment and regulatory knowledge. The nurse communicates audit findings and recommendations, educates facilities about corrective actions and compliance, works with providers and internal and external stakeholders, and protects personal health information in accordance with HIPAA. Clinical expertise is used to identify patient needs, assess appropriate care, and support decisions that improve patient outcomes. The position requires a current, active, unrestricted Massachusetts RN license and an RAC/CT MDS certification, which must be completed before the start date. Candidates must live in the Boston regional area and have reliable transportation, a valid unrestricted driver's license, and current auto insurance. The role is full-time, with an annual salary range of $72,800 to $130,000. Benefits and incentive offerings are subject to eligibility requirements.
Requirements
- Current, active, unrestricted Registered Nurse (RN) license in Massachusetts.
- RAC/CT MDS certification currently held or obtainable, with certification completed before the start date.
- At least 4 years of nursing experience, specifically in long-term care and/or medical record review, with knowledge of Medicare and Medicaid.
- Recent long-term care MMQ, MDS, staff development, or management experience.
- Experience working in medical insurance and/or healthcare industries.
- Experience analyzing inventory, researching, identifying, and resolving issues.
- Experience defining and managing processes within a team.
- Experience troubleshooting issues for users within teams, IT, and/or business partners.
- Knowledge of the healthcare insurance industry, including Medicaid, Medicare, and CMS.
- Knowledge of UM process flow, including prior authorization, concurrent authorization, and/or clinical appeal and guidance reviews.
- Must live in the Boston, Massachusetts regional area to meet daily field travel requirements.
- Ability to drive daily to locations throughout Massachusetts for onsite audits, at least 90% of the time and sometimes 100% as business needs dictate.
- Reliable transportation, proof of a valid unrestricted driver's license, and current auto insurance.
- Ability to pass a drug test before beginning employment.
Nice To Haves
- Knowledge of Medicaid and Medicare benefit products, including applicable state regulations.
- Knowledge of the applicable area of specialization.
- Knowledge of Massachusetts DPH guidelines.
- Knowledge of computer functionality, navigation, and software applications.
- Proficiency with Microsoft Office Suite.
- Proficient written and verbal communication skills.
Responsibilities
- Drive daily to facility locations within the Massachusetts territory for onsite audits, generally at least 90% of the time and sometimes 100% as business needs dictate; assist with audits elsewhere in the state when needed.
- Audit MDS assessments and entire medical records to validate coding accuracy, quality outcomes, and reimbursement integrity.
- Audit antipsychotic therapy and review other clinical indicators in support of quality improvement.
- Evaluate clinical documentation, treatments, and medication utilization using clinical judgment and regulatory knowledge.
- Review current and prior patient conditions, records, evaluations, and relevant social and economic circumstances to identify patient needs.
- Research information needed to assess records for accuracy, answer questions, and make recommendations.
- Apply knowledge of disease pathology, pharmacology, and clinical treatment protocols to evaluate care and identify appropriate courses of action.
- Communicate audit findings, rationale, and recommendations to providers, facility leaders, peers, and interdisciplinary teams.
- Educate nursing facilities and stakeholders about audit results, corrective actions, best practices, and compliance standards.
- Collaborate with internal and external stakeholders, including peers, team members, case managers, and field care advocates, to improve care quality and determine appropriate follow-up or referrals.
- Discuss patient care details with peers and providers in relation to patient care and benefits.
- Maintain compliance with HIPAA and applicable privacy and confidentiality requirements when communicating about protected health information.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs, subject to eligibility requirements.
- Equity stock purchase, subject to eligibility requirements.
- 401(k) contribution, subject to eligibility requirements.
- Career development opportunities.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
